Abstract

People who are admitted to acute psychiatric wards need psychological as
well as pharmacological treatments, but psychological care is not always
available in the acute setting. Group psychotherapy can prove a practical and
cost-effective answer to this unmet need in service provision. We describe a
psychotherapeutic group that our team has implemented on our busy, inner-city,
male-only acute ward, which has been running successfully for over 2 years and
has since become an integral part of the acute care we provide to our
in-patients. Group therapy can enhance individuals' adherence to treatment
plans, reduce reliance on pharmacological approaches, pre-empt untoward
serious incidents and potentially reduce patients' duration of stay. In
addition to addressing the psychological needs of acutely unwell people, group
therapy is beneficial to the clinical team by promoting a better work and
therapeutic environment on the ward.

Following the advent of newer community services (Smith, 2003;
Johnson et al, 2005),
inner-city acute wards now operate under unremitting pressure, admitting for
shorter lengths of stay patients who are increasingly unwell
(Dratcu, 2006). Although
medication is almost always the first line of treatment, psychotherapeutic
interventions may be as important but are not always available. Group therapy
can successfully address this need in service provision if tailored to this
setting. We describe a psychotherapeutic group we have developed to suit the
needs of the adults admitted to our busy, inner London, male-only acute
ward.

Group psychotherapy, a neglected therapeutic tool

Psychological treatments should play a crucial part in mental healthcare
but are not always accessible to those admitted to acute in-patient units,
precisely where psychological approaches may be most needed
(National Institute for Health and Clinical
Excellence, 2005). As psychology services have never been
available to our unit, a 18-bed acute ward that admits over 200 male patients
a year and where bed occupancy consistently exceeds 100%, our pro-active
occupational therapists have endeavoured to provide psychological input for
our patients by offering a range of programmes, from community and educational
groups to physical activities. With a view to promoting a better therapeutic
milieu on the ward and further improving our standards of care, we thought we
could use our own home-grown experience to implement a more formal model of
psychological care that was compatible with both our setting and our
resources. Group psychotherapy seemed a promising option.

Group psychotherapy in the acute setting has been virtually abandoned in
recent years. Increased work pressure, changes in working practices and
financial constraints may all be to blame. As a result, in-patient mental
health teams may now be reluctant to implement a useful therapeutic activity
with which they may no longer be familiar. Moreover, most models of
out-patient group therapy currently on offer cater predominantly for people
with neurotic or personality disorders who undergo lengthy selection
procedures, and are therefore difficult to replicate in the acute setting. As
is the case in our service, individuals who are admitted tend to be severely
ill, typically suffering from psychotic or major affective disorders which are
often complicated by substance misuse and an array of social and legal
problems (Dratcu et al,
2003). Many are compulsorily admitted and may be seen as too
unwell or unmotivated to engage in a therapeutic group. In search for a
practical solution to our quest, we revisited different models of in-patient
group therapy, including Yalom's
(1983,
1985) and Kanas'
(1996,
2000).

Planning group psychotherapy

Yalom's model

Models that are based on specific diagnostic categories (e.g.
schizophrenia), such as Kanas'
(1996), would be unlikely to
cater for the clinical diversity of the individuals who are admitted to our
unit and who otherwise could benefit from group therapy. In contrast, Yalom
(1983,
1985) had previously designed
a format of group therapy specifically for the acute in-patient setting that
is largely unconcerned with diagnostic boundaries and that was commonly used
in past years. Rather than aspiring to accomplish overly ambitious goals, the
main purpose of Yalom's in-patient group is to facilitate interpersonal
interactions among the patients themselves and between the patients and the
clinical team, their families and their friends. It also aims at helping
individuals to understand better their current difficulties, both inside and
outside the hospital environment. This model prescribes group sessions 5 days
a week, lasting 75 min and ideally involving six to eight patients each, that
should be facilitated by doctors and nurses, and where each session is seen as
a `single entity'.

Yalom suggested six basic achievable goals for in-patient group therapy:
engaging patients in the therapeutic process; demonstrating that talking
helps; problem spotting; decreasing isolation; being helpful to others; and
alleviating hospital-related anxiety. Facilitators must adopt a clearly
pro-active role and ensure that the group feels safe and constructive. Unlike
some forms of out-patient group therapy, in-patient group therapy should avoid
or dispel conflict and tension, as on acute wards the aim to provide a
containing environment takes precedence over the scope for confrontation or
expression of anger.

Preparing the team

Yalom's model seemed to offer us some major advantages. First, its
eclecticism appeared to suit the heterogeneous clientele that we see on our
ward. Second, we could capitalise on the existing skills and motivation of our
team to implement it, while the team could develop and practise new skills in
the process. Third, relying on our own workforce to provide psychological care
to our patients meant that there was no need to recruit external therapists
who, at any rate, would be unfamiliar with the ward. Finally, expertise for
supervision was available from another local service, which we could approach
for this purpose.

The senior manager of our local group psychotherapy day service agreed to
supervise a core team of six facilitators from our ward. Medical participation
was seen as essential from the outset to consolidate the group and make it
truly multidisciplinary, and also to demarcate its place in our clinical
routine. In addition to the associate specialist, nurses, support workers and
the occupational therapist, all of whom had some of experience of group work,
volunteered to join the project.

In the course of several preparatory meetings between the supervisor and
the facilitators, Yalom's model was discussed in the light of our
circumstances, and adapted accordingly. Although we were unable to offer group
sessions on a daily basis, we agreed that we could provide group psychotherapy
sessions on a weekly basis. Once the group was established, two to three
facilitators should participate in each therapy session, whereby one
experienced facilitator would initially lead the group assisted by at least
one inexperienced one. Thereafter, facilitators would change each week so that
all could hone the relevant skills. We also agreed that supervision sessions,
covering facilitation methods as well as organisational and practical matters,
should henceforth continue regularly every 2 weeks and be attended by as many
facilitators as possible. Finally, to effectively convey the purpose of the
group to our patients, we decided to call it the Communication Group.

The group begins and evolves

After the team of facilitators felt ready to start, posters were displayed
on the ward informing in-patients about the Communication Group, which would
meet once a week. People were invited to join by members of the team or when
seen during ward rounds. The need for screening procedures was reconsidered
after individuals who at first were thought unsuitable to participate
eventually proved able to contribute positively to the sessions. From then on
patients were excluded only if they were felt unlikely to stay for the
duration of the meetings or likely to pose a risk of harming themselves or
others during or after the sessions. Most were invited to attend as soon as
they had been admitted.

Two months after its launch, the Communication Group had established itself
as a landmark in the ward's therapeutic programme. We had to expand our core
team of facilitators to at least eight people to ensure that enough
facilitators were available each week, which has been made possible by
coordinating the group activities with the nursing shifts. The group has now
been running successfully for 2 years, during which period it has held over
100 weekly sessions. Well over 200 different patients have participated on at
least one occasion.

Group sessions

From the beginning, the Communication Group sessions have adhered to the
same format and been held in a designated room on the ward itself, to attract
and encourage participation. Each session lasts 50 min and starts with a clear
statement by the main facilitator explaining its purpose, how long it will
last and that participants do not have to talk if they do not wish to. Then
all participants are invited to introduce themselves in turn. In the attempt
to introduce `here and now topics', the facilitators may ask individuals to
briefly mention the reasons for which they think they have been admitted to
hospital, unless patients spontaneously indicate other topics they may wish to
address. During the last 5 min, all participants, including the facilitators,
are invited to comment on the session and on what has been learned from it. At
the end of each session, the facilitators meet for a further 15 min to discuss
the proceedings. The progress of the group and of the facilitators is reviewed
in supervision sessions every 2 weeks.

The number of patients varies up to a limit of ten, averaging eight per
session, and no two sessions have included exactly the same people. Most
sessions run smoothly and almost spontaneously, when conversation usually
flows easily and individuals respect each other's turn to speak. On some
occasions, however, facilitators have to play a more active part and, at
times, keep the group focused on `here and now issues'. For example, skilled
facilitation has prompted participants to confront major factors contributing
to admission, such as alcohol and substance misuse, that otherwise would be
unlikely to be fully addressed elsewhere. Of note, there has never been any
aggressive or serious incident in the group and relatively few people have
ever `walked out' from the sessions, even though they are allowed to leave if
they feel uncomfortable. Very rarely has someone been requested to leave for
being disruptive to the activities.

Group psychotherapy: welcomed by patients, embraced by the clinical
team

By offering our patients the opportunity to safely disclose and debate
critical issues on a structured and regular basis, and our multidisciplinary
team the opportunity to develop and practise newer therapeutic approaches at
the workplace, the weekly group sessions have clearly fostered a therapeutic
environment on the ward.

Audit is ongoing, but there are preliminary indications that the
Communication Group has played a prominent part in improving people's
satisfaction with hospital treatment and reducing the number of untoward
serious incidents on the ward. It may have also contributed to both enhance
patients' adherence to their treatment plans and reduce reliance on
pharmacological treatments, particularly `as required' prescriptions. To our
multidisciplinary team, participating in the Communication Group has
represented an educational experience that is unlikely to be available
elsewhere. As the growing number of facilitators feel empowered to apply their
newly acquired skills into other aspects of our clinical routine, the gains to
the service have extended beyond the weekly sessions alone. Not only do
facilitators feel more actively involved with patient care, and with the whole
therapeutic process that defines hospital care, but their input is valued by
the clinical team at large. This has promoted a sense of team identity and
boosted morale which, in turn, has generated a better work environment, to the
benefit of all.

Now that the group has consolidated, nursing students and trainee doctors
are also encouraged to take part, thereby enriching their training with
practical communication and psychological skills that they may use in a range
of professional settings. The Communication Group has also attracted interest
from other acute services, including requests from colleagues both within and
outside our own Trust to attend as observers.

Psychological care on acute wards: group psychotherapy as the way
forward?

The benefits to patients of psychological care on a structured and regular
basis as part of hospital care was acknowledged in the best traditions of
psychiatric hospitals of a not-so-distant past
(Wing, 1990). No less should be
expected from a modernised mental health service, but this is not usually on
offer on today's acute wards. Current practice favours behavioural methods
that focus primarily on the management of disturbed behaviour
(National Institute for Health and Clinical
Excellence, 2005), yet the psychological needs of acutely unwell
people go far beyond those that can be met by de-escalation techniques and
similar ad hoc strategies. If anything, the effectiveness of such
approaches in preventing potentially violent situations serves as a clear
reminder of the scope for psychological interventions in the acute setting,
where the vast majority of individuals are not always agitated.

Implementing group psychotherapy in the acute setting involves some obvious
challenges. The first is the task of motivating the team and attracting enough
facilitators, as additional time and effort will be required, at least
initially, from clinical teams already coping with heavy workloads. Second, it
is crucial to negotiate high calibre supervision regularly as well as medical
participation from the outset, yet qualified supervisors may not always be
available. Third, any such project needs careful planning before it is
launched. The Communication Group could start and evolve only after we
adjusted an established model of group therapy to the constraints of our
setting, with all the preparation this entails. Finally, it should be seen as
a formal part of the ward's clinical routine, and one that requires commitment
from the team in the long term so that it remains appealing and attractive to
individuals who are admitted. From the patients' perspective, the motivation
to attend is bound to be largely associated with the expectation that the
sessions represent a positive and valuable experience. The group is always
mentioned in the ward's daily planning meetings and our nurses personally
invite individuals to attend on the morning prior to the sessions. Yet,
perhaps a chief factor contributing to patients' continued attendance is that
many of the ward staff are themselves the facilitators, including one of the
senior psychiatrists.

By optimising existing resources and adapting Yalom's model to our acute
setting, our team was able to introduce weekly group psychotherapy to our
ward, thereby devising a practical and cost-effective way of providing
psychological care to our patients as an integral part of their hospital care.
Our experience has also shown that acutely admitted patients who are severely
unwell, as is the case with our clientele, may all not only potentially engage
with group therapy but also actually gain from it within the context of the
six goals delineated by Yalom. In the group sessions, staff and patients talk
openly about aspects of their treatment. Patients are encouraged to bring
their concerns for discussion and explore the rationale for their treatment,
and are also given the opportunity to question staff about this. The team, in
turn, has benefited from a better and more rewarding work environment.

Formal scrutiny of this and other indices, such as the impact of the
Communication Group on patients' duration of stay and satisfaction, still
needs to be completed. Moreover, as individuals' participation is
automatically terminated once they are discharged from the ward, the
implications of this are unclear. Similar forms of psychological care are
unlikely to be offered in the community to those who wish to continue
attending the group. However, rather than being a shortcoming of the
Communication Group, perhaps this should be seen as a reflection of
shortcomings in the provision of psychological care to these people in the
community. Whether group psychotherapy could fill in this gap in the community
as well as in the in-patient setting is also a question that warrants further
scrutiny.

Acknowledgments

The authors thank Nazma Soormally, Ward Manager, whose continuous support
has been vital to the success of the Communication Group.